Outpatient therapy gets outlined as a therapeutic treatment that is available to patients who live away from a hospital or medical facility. The approach to treatment is significant in aiding patients to take part in the treatment, alter how they behave, and their attitudes towards problems. It is also possible to gain more skills of healthy life. The treatment approaches enable medications to be more appropriate and helps the patient to stay in treatment for longer time. There are a number of treatment approach therapies that are used in attending outpatients, which include 12-step facilitation therapy, cognitive-behavioral therapy, motivational therapy, therapeutic community therapy, matrix model, and community reinforcement and contingency management. These therapy approaches are classified into classical conditioning and humanistic therapy. They depend on the patients’ or clients’ reaction to the approach effectiveness, whether through behavior approach, relationship with friends and family or on the drug therapy. Basing the focus on matrix model, and community reinforcement and contingency management, their effectiveness is established on a lot of dedication and positive performance (Woody, 2003).
Matrix Model is an immensely applicable treatment approach which became introduced in 1980s as a way of treating the huge population, who were addicted to stimulant drugs such as cocaine. This approach is acceptable for clients, who need full care. This is because medical practitioners planned such a method of treatment so that it can act as intensive intervention, compared to the past approach. Additionally, this method includes weekly counseling of outpatients, or treatment of inpatient within 28 days.
The model, which was in the past referred as neurobehavioral treatment, may necessitate numerous additional treatment approaches such as, cognitive-behavioral, motivational enhancement as well as 12 steps. This will help in addressing problems related to patients’ emotional, relationship, cognitive and behavioral issues.
Predication of the Matrix Model treatment approach is on teaching the clients or patients how to initiate a healthy and orderly lifestyle, and how to structure time. It establishes a strong relationship based on therapeutic between the counselor and the patients or clients. It provides extra opportunities to them on learning and practicing the hindrance of relapse and coping techniques, encouraging them to take part in mutual-help groups, which are often based in the community. It also helps in imparting comprehensible information, which is accurate about sub acute and acute effects of withdrawal, and substance cravings, including family members and other people, who are necessary in the educational and therapeutic processes, to gain their support for treatment, and prevent their treatment quitting. Above all, this approach is extremely vital in carrying out urinalyses test or random breath in order to establish the treatment that is most applicable.
In order to ensure that the model is effective, some of model’s variations have been designed. Twelve-month version is a good example of developed variations, and it involved a start with thorough treatment for six months. This comprises of 56 sessions of personal counseling. It is made up of co-joint sessions with the family of the affected, and clients attending the sessions for treatment at least three to four times every week. The individual sessions for patients, involved supplementing through social support groups, prevention of an elapse, family participation, as well as education. The original specific treatment protocol for cocaine was followed by versions of people who used opioids or alcohol primarily. Later a 16-model version was developed, in which the individual sessions number were three because of the cost constraints that also emphasized group work (Plakun, 2011).
In all the Matrix Model treatment approach versions, coordination of clients’ or patients’ treatment experience is done by a primary therapist, where their relationship, including that of the family members, is critical to the process of treatment.
The focus of individual sessions is on planning the treatment and progress evaluations and may include the patients’ or clients’ family members in a part of the session. In addition, the 16-weeks treatment protocol includes groups, which are specifically structured and include:
Groups of patients who normally recover early in the treatment. This is normally a small number. They play a major role in increasing the attention extended towards every patient or client, and is usually applicable to patients, who are in their initial months of treatment. The groups pay more attention to the treatment of patients, making sure information is available on how to manage cravings, and application of cognitive tools. The group also focuses on management of time, and helps patients in accessing support services of the society. Patients or clients make a program and assess their daily activities with group support as well as input.
The sessions on family education, includes both family members and clients. They are presented as a 12-week series. Activities that take place during the sessions include discussions on topics like medical effects of substances, addiction biology, effects of addiction on the family members, and conditioning. These discussions are carried out in groups. There is also panel presentation videos and slide show presentations.
Relapse presentation groups are the first components for treatment. These sessions are immensely structured on behavioral and cognitive changes. They pay huge attention to connection of client to programs of mutual help. Their guidelines include 32 specific topics.
Protocol treatment also comprises of Social support groups. This start in the last month of treatment concentrates on assisting the patients practice activities that do not involve the use of drugs. In addition, it helps patients to develop friendships and relationships with individuals who do not use drugs. Social support groups are less organized, compared to other groups, and the constitution is usually determined by the needs of group members.
The Model program orients clients or patients to 12-step programs, and often schedule onsite meetings of the 12-step. Clients or patents are encouraged to attend additional meetings in the community, and find a sponsor for 12-step.
The Matrix Model approach has several strengths that help in its effectiveness, which include integrating a cognitive-behavioral concept, including the family into the process. It also includes a 12-step support, psychosocial education and testing of urine; following a manual, which provides the therapist with practical exercises and specific instructions, where the versions of the model materials are available free at the National Clearance house for Drug and Alcohol Information. The Matrix model has proved its viability due to the fact that it is applicable to individuals who are intensely dependent on stimulants.
Besides the strengths, this treatment method has various challenges, which comprise of the need to transform several materials for patients, who have impaired cognitive functioning. It also involves the need of special personnel training and supervision in the program. However, the highly structured program may not be appealing to all clients. The rigid structure and program may also fail to create time for identifying and stabilizing of other problems that may not be related to drugs.
Staffs, which consist of high skilled therapists in the Matrix Model, are very important in the effectiveness of this approach. This is because of the expectation that, they are to come up with a non-judgmental nurturing relationship, improve their clients dignity and self-esteem, maintenance of a support attitude in case of relapse of a patient, and play the role of coaches or teachers without being either confrontational or parental. Patients, who stay away from drugs for a long period, sometimes act as co-leaders in groups, role models, and they prove to others that it is possible to recover. The treatment approach is more successful in hospitals, substance abuse treatment centers and hospitals which are diverse settings.
Studies advocate the Matrix Model treatment method utility, individual selection of the 28 days program, or 12-step group participation. This method leads reportedly lower rates of cocaine use, eight months after a patient gets treatment if compared to those in other groups. Additionally, the Matrix Model researches revealed effective result during treatment of patients involved in abuse of methamphetamine. This is due to the fact that it helped in reducing other infections, emerging due to misbehavior of individuals due to the influence of the drug.
Community reinforcement and contingency management are another treatment approaches that work hand in hand based on the theory of operant conditioning and is applied on day treatment settings and intensive outpatient. The theory maintains that the behavior of the future is based on the consequences of the past behavior, whether negative or positive. For example, the use of the drug is maintained by the reinforcing effects of it, which are positive, or by the reinforcement of relieving withdrawal pain, which are negative. Abstinence may not be reinforcing sufficiently, of and itself, to maintain motivation of a person to stop drug use, especially in early abstinence. There should be made other rewards in order to strengthen the transformation of lifestyle and the lasting abstinence.
Contingency management being an approach by itself, its intervention of operators is the main tool for treatment used in community reinforcement. The negative and positive reinforcements that characterize contingency management in community reinforcement are understood to be mediated socially. Community reinforcement uses clients’ or patients’ life, which involve hobbies, job, relationships with many members of the family, relationship with friends as well as social events, to provide reinforcement that is positive, and which motivates them to stop substance use. Community reinforcement and contingency management approaches motivates the behavioral change of a client or patient, and systematically reinforces abstinence by rewarding behaviors, which are desirable, and punishing or ignoring others. The rein forcers are typically pleasurable, positive, rewarding objects or events, but some negative rein forcers are also effective. A case of a negative reinforcement is discharging a restriction or a fine after a client or patient has recognized a specified course of therapy.
Identifying a reward on behavior that is desired, which is both sufficiently powerful and practical over time, to substitute or replace for the pleasurable pain reducing or portent effects of the drug, is quite a challenge in this treatment approach. The reward must be available without too much expenditure or cost of the staff energy. The punishments and rewards must be carefully tailored to the response of the patient or client and different capabilities of the program. Most of the voucher-based or financial interventions of contingency management use series of rewards, which are escalating for target behavior achievement like, specimens of urine, which are drug free. The escalating rewards provide an incentive, which is greater for desired behavior sustenance. When a larger reward is given at the treatment beginning, followed by a couple of increased earning vouchers requirements within the process of treatment, there is a greater reduction in use of drugs, like cocaine.
Community reinforcement involving vouchers is an approach where the reinforcement of abstinence depends on voucher awarding. There is a teaching of relapse prevention techniques and skills of drug avoidance, alongside relationship counseling, recreational and social counseling, and social and other training skills. Clients get points for every negative urine screen for cocaine or other types of drug being abused. The point number rises with every successive screen of negative urine. In the event that positive urine specimen for cocaine or any other form of drug is submitted by the patient, the points’ value go back to baseline and the only method of getting the points back is through complying five successive specimens of negative urine. The points earned are not redeemed for cash, but for a variety of retail items purchased by the program staffs that have veto power over the requests of clients. The members of staff only approve items which are consistent with treatment goals of a client, and encourage activities which are drug free. Patients within the program can purchase items like continuing education materials, ski lift tickets, baby clothes, toaster ovens, bicycle equipments, and camera equipments.
For both treatment management and community reinforcement programs to be resourceful, targeted behavior must be established. This behavior can normally be achieved within a given period. It usually has a direct effect on the result that is desired. For example, it may be optimistic to expect clients or patients who have never submitted a sample of drug-free urine to achieve abstinence, which is immediate. Specific substance abstinence might precede all substance abstinence. An effective strategy is targeting changes that are small. More rein forcers, which are frequent, whether small; have an effect that is greater than larger, more punishments or remote rewards. It is vital that contribution to the goals of treatment is being made by desired behaviors. For the treatment to remain credible, all rewards must be delivered as promised. People who merely attend sessions of counseling may not affect their drugs abuse.
Contingency management interventions depend on precise and detailed measurements of targeted behavior, rather than the requirement of specialized assessments and instruments of treatment, planning for successful implementation. It is difficult to monitor abuse of alcohol using the procedures of contingency management, because it has a short half-life. In order to award vouchers, the status of drug use must be determined by testing observed specimens of urine frequently, rather than relying on the self-reported status of drug use. There is a need to use measures that are objective and verifiable, which demonstrate accomplishments. Schedules of activities used in community reinforcement and contingency management programs vary dramatically. In a day hospital, the activity program plan is normally based on intensive reinforcement support of contingence abstinence. Patients are trained on importance of access to food and housing; groups are involved in finding jobs training of social skills, and activities of recreation. The program requires patients detoxified from drugs, like cocaine and heroin, to seek treatment as a matter of urgency. This is usually for at least six hours per day on weekdays, and three hours on the weekends. This gets done for the first two weeks and the next six weeks focus upon personal counseling sessions for about one hour three times a week. In contrast, a program of six months for community reinforcement composes of voucher treatment involved sessions of individual counseling. This takes one hour twice a week and screening urine three times per week in the first twelve weeks.
Community reinforcement and contingency management treatment approaches have strength to help in their effectiveness. It includes reduction of the usage of drugs significant with the use of incentives. The approaches can be readily combined with other pharmacotherapy’s and psychosocial interventions. Both approaches can be implemented with a variety of incentives, which are of low cost like, goods, and services which are donated; the approaches have proved to be effective in drug use reduction and in treatment compliance increase among clients or patients with problems, that are severe and which are dependent on substances chronically. The methods also have a strong scientific support when studied in the clinical or in the laboratory.
Besides the strengths, the approaches also face some challenges, which include clients or patients returning to baseline rates of drug use after the termination of incentives, the approaches requiring specialized training or staff for implementation, being labor intensive and entailing client or patient attendance, which is frequent. It also includes the need for larger rewards and a growth in their value in order to have an appeal to clients or patients that is continuing for maximal effectiveness. There may be a lack of resources required for the implementation of community reinforcement and contingency management approaches, for example, the onsite capabilities of urine testing or alternatives to incentives, which are costly. It is a potential drawback due to lack of emphases of supports that are long term, and incurrence of incentive costs on small samples.
Behavioral intensive contingency management interventions have been effective with people abusing cocaine, pregnant women, homeless persons, and with individuals who are on methadone and who need to discontinue the abuse of other drugs. The interventions have been used with other clients or patients who are resistant to treatment and have severe problems related to housing or employment, or who have medical or psychological conditions and have been unsuccessful in abstinence achievements through the methods of traditional counseling.
The expense of incentives, extra urine screens and the extra demands of time placed on members of staff, affect the cost of effectiveness of community reinforcement and contingency management. Alternative incentives of low cost can be used to bolster interventions of traditional treatments effects, while donated services and goods can reduce community reinforcement and contingency management cost. Some of the motivations that can be used include clinic fee reduction, protective service workers, anniversary celebrations, supporting letters to employers and specific books.
Contingency management approach to substance use disorders has proved to be effective in clients or patients motivation, to achieve and sustain abstinence, besides increasing their compliance with other objectives of treatments. An impetus for managing the abuse of drugs has been granted by the National Institute on Drug Abuse manual, using techniques on contingency.
The manual presents five clinical trials, which are controlled, findings that supported community reinforcement plus vouchers superiority over the care of standard. In one of the studies, seventy-five percent of the participating clients or patients completed the program in community reinforcement plus vouchers, compared with the eleven percent clients or patients of the standard care. Adding vouchers that are redeemable was more effective than a standalone community reinforcement treatment, according to two subsequent studies. There were positive effects found on the dependence of cocaine in eleven out of thirteen studies in a literature review of similar approaches of community reinforcement. Other researchers showed that, there was a significant increase in abstinence during treatment and following a year after it, in delivering possibilities based on the urine test results, which were proved to be cocaine free.
Another contingency management landmark study, examined the incentive housing effectiveness for crack cocaine use reduction among homeless people. Drug-free housing incentive and social and recreational activities vouchers, were viewed to be more effective than the treatment orientation of the 12-step alone, for the reduction of cocaine and alcohol use as well as the issue of homelessness.